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EHR Payment Incentives for Providers Ineligible for Payment Incentives and Other Funding Study

APPENDIX K. GRANT, DEMONSTRATIONS, AND COOPERATIVE AGREEMENT PROGRAMS

This appendix provides a program summary of the grants, demonstrations and

cooperative agreement programs that have a focus on HIT and ineligible providers. Program highlights are presented in table format followed by a narrative description.

The last section of the appendix includes a summary of the proposals advanced by

various stakeholder groups to extend grants, demonstrations and cooperative agreement programs that have a focus on HIT to some ineligible health providers.

A. Program Highlights

Authority and Funder

Description Recipient: State or Provider

Geographic Location

Provider Type

Impacted

Amount (if known)

ONC: ARRA/HITECH

State Health Information Exchange Cooperative Agreement Program

Authority1

State or State Designated Entity

Nationwide All State Specific

Medicaid Grant/CMS

Medicaid Health Home

State Plan Option2 90%

Federal match for 8 quarters.

Health Home Providers

State Determined -- Less than Statewide

Health Home Providers

State Determined

HRSA Capital Improvement

Projects (CIP)3

ARRA Funding opportunity for existing health center grantees for capital improvement and employment opportunities in underserved communities. Health IT projects included the enhancement or the purchase of new EHR systems.

Providers Safety Net Providers

$183,101,679

HRSA Health Center Controlled

Network (HCCN)4

Grants support the creation, development, and operation of networks of safety net providers through the enhancement of health center operations, including health information technology

Providers Safety Net Providers

SAMHSA Grants to use web-based services, smart phones and behavioral health electronic applications to enhance communication between patients and providers and to better manage patients’ health.

Provider Awardee Geographic areas

Awardees may receive up to $280,000 annually over 3 years

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Authority and Funder

Description Recipient: State or Provider

Geographic Location

Provider Type

Impacted

Amount (if known)

ONC: ARRA/HITECH Beacon Community

Grants5

Grant program for communities to build and strengthen their health IT infrastructure and exchange capabilities. Some communities are addressing include engagement of LTPAC, BH, or Safety Net providers and/or the patients they serve.

Providers

Those BCPs that include a focus on ineligible providers: - Danville, PA - Tulsa, OK - RI - Southeast MN - HI - S. Piedmont, NC - Brewer, ME - Western NY

LTPAC Behavioral Health

- PA: $15,914,787

- OK: $12,043,948

- RI: $15,914,787

- MN: $12,284,770

- HI: $16,091,390

- NC: $15,907,622

- ME: $12,749,740

- NY: $16,092,485

ONC: ARRA/HITECH

Challenge Grants6

Challenge Grants have been awarded to state health IT programs to focus on health information exchange involving LTPAC providers.

States Challenge Grants that focus on LTPAC providers: - CO - MA - MD - OK

LPTAC CO extending grants for LTPAC organizations to connect to HIE

2011: - MA:

$1,717,610 - CO:

$1,718,783 - MD:

$1,683,171 - OK:

$1,719,086

ONC: ARRA/HIECH Technical Assistance to States through the State Health Policy Consortium (SMPC)

Help states resolve policy issues to enable electronic exchange health information across state lines (builds on the work of the HISPC project). Funding to “Pursue Initiatives to Encourage the Adoption of Certified EHR Technology to Promote Health Care Quality and the Exchange of Health Care Information”. Examples: OR, VT, IA, AL

States - Upper Midwest (ND, SD, MN, WI, IL, IA)

- Southeast Regional (AR, LA, TX, FL, GA, AL)

- Behavioral Health Data Exchange (FL, MI, KY, AL, NM)

- Western States (OR, CA, AZ, HI, UT, NV, AK, NM)

- Interface Library Project (TX, GA, VT, PR)

- Consumer Innovations Challenge (GA, IL, IN, MD, MT, and NE)

All, but Behavioral Health is a focus for one of the consortia (FL, MI, KY, AL, NM)

SAMHSA: ARRA/HITECH

This feasibility pilot program funds the effective interstate exchange of behavioral health data including substance abuse treatment records using the NwHIN DIRECT. The states of Alabama

One Health Record®, a

health information service provider (HISP), and FL HIE, a HISP, are interstate partners. April

2012 to July 2012.7

State - AL - FL - KY - MI - NM

SAMHSA/ONC Federal Grant

Behavioral Health and non-behavioral health providers.

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Authority and Funder

Description Recipient: State or Provider

Geographic Location

Provider Type

Impacted

Amount (if known)

SAMHSA: Affordable Care Act

Grants to 64 community-based health agencies. One of the services provided at the various sites is the development and implementation of a registry/tracking system to follow primary health care needs and

outcomes.8

Community-based health agencies

64 Community-based health agencies

Community-based health agencies

Community Specific

AHRQ Grant to Geisinger Health System of Danville, PA to extend the KeyHIE Connected Community to behavioral health providers.

Provider (Geisinger Health System)

Pennsylvania Behavioral Health Providers

$2.3 M over 5 years

SAMHSA Community Mental Health Services Block Grant (MHBG)

MHBG distributes funds to eligible States and territories for a variety of services and for planning, administration and educational activities under the state plan for comprehensive community-based mental health services for children with serious emotional disturbance and adults with serious mental illness. OH Department of Mental Health (ODMH) to Community Mental Health Centers to Fund Projects to Support Adoption of Health IT and Behavioral/Physical Health Care. MI Department of Community Health to PHIPs for 4 areas, one of which is promotion of EHRs.

States to fund Provider

59 eligible states and territories

- OH: Community MH Centers

- MI: PHIP

- OH: Up to $50,000 per Community MH Center

- MI: $130,000 per PHIP

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Authority and Funder

Description Recipient: State or Provider

Geographic Location

Provider Type

Impacted

Amount (if known)

Affordable Care Act Sec. 6114. National Demonstration Projects on Culture Change and Use of Information Technology in Nursing Homes

Development of best practices in skilled nursing facilities for the use of information technology to improve resident care. The demonstration project conducted under this section shall take into consideration the special needs of residents of skilled nursing facilities and nursing facilities who have cognitive impairment, including dementia. The duration is not to exceed 3 years. Within 9 months of completing project, a report shall be submitted to Congress on the project including recommendations for legislative and administrative action.

Unfunded

2041(b) of the Social Security Act, as added by section 6703 of the Affordable Care Act Programs to Promote Elder Justice SEC. 2041. Enhancement of Long-Term Care.

Certified EHR Technology Grant The Secretary is authorized to make grants to long-term care facilities for the purpose of assisting such entities in offsetting the costs related to purchasing, leasing, developing, and implementing certified EHR technology (as defined in section 1848(o)(4)) designed to improve patient safety and reduce adverse events and health care complications resulting from medication errors.

Funds were authorized but not appropriated

1. ONC, http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__hitech_programs/1487 accessed May 19, 2012. 2. CMS, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Integrating-

Care/Health-Homes/Health-Homes.htm accessed May 19, 2012. 3. See http://bphc.hrsa.gov/recovery/capitalimprovement.html. 4. See http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/OpportunitiesCollaboration/controlnetworks.html. 5. See

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__onc_beacon_community_program__improving_health_through_health_it/1805.

6. See http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3378. 7. See http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3869 accessed May 12, 2012. 8. See http://www.samhsa.gov/healthreform/healthHomes/index.aspx access May 15, 2012.

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B. Program Summary

ONC HITECH State Information Exchange Cooperative Agreement Program for State and/or State Designated Entity1

Some states have used funding through their State Health Information Exchange

(SHIE) Cooperative Agreement with ONC. The SHIE Cooperative Agreement is a grant program to support states or State Designated Entities (SDEs) as they establish health information exchange (HIE) capabilities for eligible and ineligible providers.

The SHIE Cooperative Agreement requires states seeking funding to advance the

electronic exchange and use of health information technology to develop an infrastructure that addresses the following domains: technical, technical and business operations, financial, policy and legal (e.g., privacy/security including access, authentication, and authorization), and governance. Some of the health IT infrastructure enhancements eligible for funding through a SHIE Cooperative Agreement (dependent on what the state submitted and ONC approved) are provided in Table K1.

TABLE K1. Potential Health IT Enhancements Eligible for ONC HIE

Cooperative Agreement Funding Secure Messaging

Record Locator Service

Provider Directories

Development of Privacy and Governance Policies and Procedures

Identify Management as a Common Service.

Shared Common Business Intelligence, Rules Engines and Reporting Functionality.

Supporting DIRECT Provider-to-Provider Communication

Establishment of Rules of Engagement related to Privacy and Security through Nationwide Health Information Network Data Use and Reciprocal Support Agreement (DURSA)

a and SAMHSA Qualified Service Organization

Agreement (QOSA)b

a. National e-Health Initiative DURSA Data Use and Reciprocal Support Agreement. http://www.nationalehealth.org/dursa, accessed May 19, 2012.

b. SAMHSA. "Confidentiality of Alcohol and Other Drug Treatment Records and Communicable Disease: Options for Successful Communication and Collaboration," Confidentiality of Patient Records for Alcohol and Other Drug Treatment Technical Assistance Publication (TAP) Series 13, http://kap.samhsa.gov/products/manuals/taps/13b.htm accessed May 29, 2012.

State awardees have flexibility to use funds for activities identified and agreed to

under their cooperative agreement with ONC, including funding the infrastructure to support connectivity between all providers whether they are EPs, EHs or non-eligible EHR providers. For example, Alabama is considering as an HIE enhancement the capacity for EHR support for Community Mental Health Centers that will be participating in the state’s Medicaid Health Home Initiative through the development of a web-based CCD. In FFY 2011, funding for the SHIE was 100% federal. In FFY 2012 the match rate is $7 federal to $1 state and in FFY 2013, the last year of the grant, the federal grant is $3 to $1 state. 1 Office of the National Coordinator for Health Information Technology. HITECH Programs.

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__hitech_programs/1487, accessed May 19,

2012.

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Medicaid Health Home State Plan Option2

Section 1945 of the Social Security Act, along with the guidance provided in

Center for Medicaid and CHIP Services (CMCS) Informational Bulletins and CMS State Medicaid Director Letter #10-024 of November 16, 2010,3 provides parameters for the State Plan Option for Health Homes for Enrollees with Chronic Conditions. It gives authority to State Medicaid Agencies to receive a 90 percent match for eight quarters to provide enhanced reimbursement for health home providers.

As defined by the state, health home providers may include designated providers,

a team of health care professionals (physicians, nurse care coordinators, dieticians/nutritionists, social workers, behavioral health professionals and other professionals) or an interdisciplinary, inter-professional health team. Inter-professional health teams must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers (including mental health providers, and substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians’ assistants.

The Medicaid health home benefit is targeted to Medicaid enrollees with at least

two chronic conditions or one chronic condition and at risk for another, and/or individuals with a serious and persistent mental health condition. Medicaid health home providers must have the ability to use health IT, including an EHR, to link services and facilitate communication among team members and between the health team and individual and family caregivers. Health home providers must provide comprehensive transitional care, including appropriate follow-up from inpatient to other settings. The Health Home State Plan can be a mechanism for accommodating some of the health IT expenses of those providers. The state must define in its State Plan Amendment (Attachment 4.19B, Methods and Standards for Establishing Payment Rates) the parameters of the payment to assure efficiency, economy and quality of care.

Some state approaches to leveraging the Medicaid Health Home benefit as a

vehicle to extend the use of Health IT/EHRs to support the exchange of health information on half of the persons who receive LTPAC or BH services follow. These examples are not a comprehensive list of all state approaches in this area.

Alabama: Alabama submitted a State Plan Amendment for the Health Home

benefit relates to improved care coordination through timely transmission of

2 Centers for Medicare and Medicaid Services. Health Homes. http://www.medicaid.gov/Medicaid-CHIP-Program-

Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html

accessed May 19, 2012. 3 Centers for Medicare and Medicaid Services. Letter to State Medicaid Directors re: Health Homes for Enrollees

with Chronic Conditions. (November 16, 2010) http://downloads.cms.gov/cmsgov/archived-

downloads/SMDL/downloads/SMD10024.pdf accessed May 12, 2012.

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transition records through the use of interoperable EHRs and Alabama’s HIE, One Health Record®.

Colorado: Officials from the State of Colorado indicated that they expect to

submit a State Plan Amendment for the Health Home benefit to support improved care coordination on behalf of persons receiving LTPAC services. Prior to submitting the State Plan Amendment, Colorado officials are conducting a strategic review of the various health IT and HIE activities underway and needed in their State so that when the amendment is submitted Colorado will positioned to most effectively use the time-limited enhanced federal match (available for eight quarters).

New York: One of New York’s first health home initiatives will focus on enrollees

with behavioral health and/or chronic medical conditions.4 New York anticipates targeting persons who receive long-term care services in a subsequent phase of their Health Home Program. To facilitate the use of health IT by health homes to improve service delivery and coordination across the care continuum, New York has developed initial and final health IT standards for health homes that are consistent with New York State’s Operational Plan for Health IT and Exchange.5 Providers must meet initial health IT standards to implement a health home and must provide a plan to achieve the final standards within 18 months of program acceptance.

Since New York anticipates a portion of health home providers may not utilize health IT in their current programs, health home providers must commit to utilizing regional health information organizations or qualified entities to the extent feasible and to develop partnerships that maximize the use of health IT across providers (EPs, EHs and non-eligible providers).6 New York Medicaid Health Home providers must use or have a plan for when and how they will implement an EHR that qualifies under MU.7 The New York Digital Health Accelerator (NTDHA), a joint program by the New York State Department of Health (DOH), New York eHealth Collaborative (NYeHC) and the New York City Investment Fund, is a program for 12 information technology startups or growth companies to develop products for “care coordination, patient engagement, analytics and message alerts for

4 New York Department of Health. NYS Implementation of Health Homes. (April 26, 2012)

http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/nys_implementation.htm, access

May 20, 2012. 5 NYS Health Home State Plan Amendment for Individuals with Chronic Behavioral and Medical Health Conditions

-- SPA# 11-56. Phase 1 (January 27, 2012)

http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/chronic_conditions_spa_11-

56_phase.pdf, accessed May 20, 2012. 6 Ibid., accessed May 20, 2012.

7 Ibid., accessed May 20, 2012.

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healthcare providers”.8 In addition to a $300,000 monetary award, the companies will collaborate with senior level managers at leading participating hospitals and leading digital entrepreneurs for mentorship and will have access to the digital technology that is connecting EHRs among providers throughout the state through the Statewide Health Information Network of New York (SHIN-NY). The accelerator program has already secured an initial investment of $4.2 million from backers including Aetna, Milestone Venture Partners, New Leaf Venture Partners, New York City Investment Fund, Quaker Partners, Safeguard Scientifics, and UnitedHealth Group. Applications are due June 1, 2012 with a program start date of September 10, 2012.9 Ineligible providers including the Visiting Nurse Services in two counties are participating.

West Virginia: West Virginia, like Alabama, is in the process of implementing a statewide HIE through their ONC Cooperative Agreement that will facilitate the sharing of information across various care delivery settings. All health home providers will be expected to participate in the HIE as it is implemented across the state.10 West Virginia has received a planning grant from CMS11 to develop the State Plan amendment (SPA) and the state is working closely with the West Virginia Health Improvement Institute on the development of the SPA.12 Eligibility criteria to quality for the program include for individuals with chronic conditions residence in a long-term care facility.

Beacon Community Program Grants that Support Behavioral Health, Long-Term Post-Acute Care and Other Non-Eligible Providers

ONC awarded grants to 17 “Beacon Community Programs” (BCPs) to support

innovative interoperable HIE activities. Several BCPs focus on HIE with BH, LTPAC and other providers non-eligible for the MU EHR Incentive programs. BCPs that include a focus on these non-eligible providers are described below:

Rhode Island’s Beacon Community Program: Spearheaded by the Rhode Island

Quality Institute (RIQI), the Rhode Island BCP received $15,914,787, to build upon existing strengths in developing Patient Centered Medical Homes (PCMHs) by enriching them with greater health IT to support registered, clinical decision

8 Digital Health Program Seeks Startup, Dolan, Brian (May 1, 2012) http://mobihealthnews.com/17179/digital-

health-program-seeks-startups-to-redesign-medicaid-care/, accessed May 2, 2012. 9 Brian Dolan. Digital Health Program Seeks Startup (mobihealth news May 1, 2012)

http://mobihealthnews.com/17179/digital-health-program-seeks-startups-to-redesign-medicaid-care/ accessed May

2, 2012. 10

West Virginia Health Home State Plan Amendment template (February 15, 2012 draft)

http://www.wvahc.org/downloads/Draft_SPA_re_health_homes.pdf accessed May 15, 2012. 11

Substance Abuse and Mental Health Services Administration. Medicaid State Plan Amendment for Health Homes

Planning Grants,

http://www.samhsa.gov/healthreform/docs/Health_Homes_Planning_Grants_for_Medicaid_508.pdf accessed May

15, 2012. 12

National Academy for State Health Policy. "West Virginia" (updated June 2011), http://www.nashp.org/med-

home-states/west-virginia accessed June 1, 2012.

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support tools, and health care quality reporting to drive improvements. Rhode Island, which has implemented a HIE system called current care, seeks to reduce the impact of undiagnosed, untreated depression through increased screening.13

Southeastern Minnesota Beacon Community: The 11-county Southeastern

Minnesota Beacon Community, which received $12,284,770, has been identified as one of the most advanced communities in terms of health IT. Virtually 100 percent of primary care providers in the area have EHRs, and Winona County has a decade of experience with “wired” connectivity of health information among health care and community partners. This Beacon Community seeks to facilitate better care coordination and clinical transformation among clinics, hospitals, the public health department, and schools in the community. In Olmsted County, it has been shown that sharing action plans for children with asthma across primary care clinics, schools, and the public health department reduces health care utilization and improves school attendance.14

Southern Piedmont Beacon Community (SPBC): The SPBC received

$15,907,622 to serve a three-county area in North Carolina that has extensive EHR adoption, including all three nonprofit hospitals and the VA hospital, and close to 60 percent of the ambulatory care physicians in the area. SPBC is expanding the benefits of the care management model to other chronic diseases as well as increasing effective use of technologies to support early detection services, such as mammograms and colorectal cancer screenings. The goal of the SPBC is to use health IT to support increased communication and collaboration among members of the care team, including care managers, pharmacists, and mental health counselors, through specialized software notification to care managers when patients are due to be discharged so that plans can be made for a smooth transition from hospital to home or other health care settings.

Care managers and nurse practitioners, armed with laptops and access to EHRs and other information; provide home visits to patients within three days following hospital discharge. Computer software allows care managers and other clinicians to identify patients with ischemic vascular disease (clogging of the arteries) to ensure patients receive evidence-based interventions and appropriate monitoring of blood pressure and cholesterol levels. School nurses monitor students who have asthma and send updates to the child’s primary care providers through a secure portal that will be available to their primary care

13

Office of the National Coordinator for Health Information Technology. Rhode Island Beacon Community.

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__rhode_island_beacon_community/3330

accessed May 25, 2012. 14

Office of the National Coordinator for Health Information Technology. Southeastern Minnesota Beacon

Community. http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_0_7982_3324_21241_43/http%3B/wci-

pubcontent/publish/onc/public_communities/_content/files/se_minnesota_beacon_summary.pdf accessed May 24,

2012.

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pediatricians. Inhalers with GPS tracking capabilities, coupled with smart phone and web-based applications, are helping approximately 2,000 asthma patients manage their condition better.15 To improve care coordination, care managers, mental health counselors and pharmacists are being added to the health team for individuals with certain chronic diseases.

Keystone Beacon Community Program (BCP): The Keystone BCP will extend

the health infrastructure used in this Pennsylvania community by enabling LTPAC providers (even those without EHRs) to make available in their data repository clinically-useful assessment data. Assessment data will be summarized, transformed, and made interoperable by software running at the repository. Assessment Summary Documents and other clinical information are made available at the repository to authorized users using a patient identifier. Keystone is presently piloting the use of a document exchange standard previously endorsed by ONC. In December 2012, Keystone will conduct a Phase 2 pilot using the refined C-CDA.16

Bangor Beacon Community: The Bangor BCP focuses on improving the health

of patients with diabetes, lung disease, heart disease, and asthma by enhancing care management; improving access to, and use of, adult immunization data; preventing unnecessary ED visits and re-admissions to hospitals; and facilitating access to patient records using health information technology. To achieve their goals they are using information technology to enhance coordinated care management, improving access to adult immunization data, reducing unnecessary emergency department visits and readmissions through health IT, and facilitating patient access to their records.17

Hawaii County Beacon Community: The Hawaii County BCP is improving the

health of the Hawaii Island residents through health care system improvements and interventions across independent hospitals, physicians, and physician groups and in partnership with public and private health insurers. Engaging patients in their own health care is also a primary focus. This will be accomplished by implementing a patient-centered medical home and telemedicine to improve primary, specialty and behavioral health care; monitor patients more closely to avert onset and advancement of diabetes, high blood

15

Office of the National Coordinator for Health Information Technology. Southern Piedmont Beacon Community.

http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_0_7985_3327_21244_43/http%3B/wci-

pubcontent/publish/onc/public_communities/_content/files/southern_piedmont_beacon_summary.pdf accessed May

23, 2012. 16

Office of the National Coordinator for Health Information Technology. Beacon Community Program: Improving

Health through Health Information Technology,

http://healthit.hhs.gov/portal/server.pt?open=512&objID=1805&parentname=CommunityPage&parentid=2&mode=

2&cached=true accessed June 1, 2012. 17

Office of the National Coordinator for Health Information Technology. Beacon Community Program: Improving

Health through Health Information Technology. http://www.healthit.gov/policy-researchers-implementers/beacon-

community-program accessed November 20, 2012.

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pressure, and cholesterol; reduce health disparities for Native Hawaiians; and assist physicians in achieving meaningful use of electronic health records.18

Western New York Beacon Community: The Western New York BCP is working

to close gaps in service, and improve health outcomes for patients with diabetes by reducing emergency room visits, hospitalizations and readmissions; increasing control of their condition, improving smoking cessation, increasing flu immunizations, reducing disparities especially in urban and rural underserved areas through health IT to facilitate patient monitoring and treatment; and by expanding patient access to their health information.19

Infrastructure: ONC Challenge Grants for LTPAC

ONC awarded LTPAC Challenge Grants to four states to extend their state health

IT infrastructure to include LTPAC providers. The focus of these challenge grants is described below.

Massachusetts Technology Park Challenge Grant: Massachusetts Technology

Park was awarded two HIE Challenge Grants ($1.7 million for improving long-term and post-acute care transitions and $1.6 million for fostering distributed population-level analytics).20 The Massachusetts Challenge grant will extend the State health infrastructure by deploying software (and perhaps hardware) to enable the interoperable exchange of: (i) data from LTPAC providers (even if they do not have EHRs); and (ii) inclusion of functional status, cognitive status, and pressure ulcers data from other health care providers (e.g., EPs and EHs). Massachusetts will pilot this exchange in late 2012, and expects later to extend this technology statewide.21

Colorado Challenge Grant: As the state designated HIE, Colorado Regional

Health Information Organization (CORHIO) was awarded a grant of $1,718,783 in 2011 to facilitate adoption of EHRs and measure the impact of HIE on LTPAC transitions.22 CORHIO is working with LTPAC organizations, including home health, hospice, skilled nursing, assisted living, long-term acute care hospitals and residential care facilities for the developmentally disabled to improve care transitions to and from acute care settings through the HIE. The goals of the

18

Office of the National Coordinator for Health Information Technology. Beacon Community Program: Improving

Health through Health Information Technology. http://www.healthit.gov/policy-researchers-implementers/hawaii-

county-beacon-community accessed November 20, 2012. 19

Office of the National Coordinator for Health Information Technology. Beacon Community Program: Improving

Health through Health Information Technology. http://www.healthit.gov/policy-researchers-implementers/hawaii-

county-beacon-community accessed November 20, 2012. 20

Office of the National Coordinator for Health Information Technology. Health Information Exchange Challenge

Grant Program. http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3378 accessed May 15, 2011. 21

Ibid., accessed June 2, 2012. 22

Colorado Regional Health Information Organization (CORHIO) LTPAC Transitions Program.

http://www.corhio.org/for-providers/long-term-care/ltpac-transitions-program.aspx accessed May 22, 2012.

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program are to facilitate adoption of HIE by the LTPAC community, develop community protocol for information sharing across care transitions, and measure the impact of HIE on quality of patient care and rates of hospital readmissions.

In four diverse Colorado communities (Boulder County, Colorado Springs, Pueblo, and the San Luis Valley), CORHIO is working with LTPAC organizations to demonstrate the value of participating with the rest of the local and statewide health care community in improving information sharing and care coordination through HIE. CORHIO has identified 320 LTPAC providers in the targeted communities, with a goal of 50 percent (160) participating in HIE by January 2014.23

The first tier of qualified LTPAC applicants will receive funding from the Challenge Grant sufficient to cover: (i) the cost of their one-time set up fee of $2000; and (ii) the cost of two-years of monthly subscription fees for use of CORHIO’s HIE. The second tier of qualified applicants will receive funding sufficient to cover: (i) the cost of a one-time set up fee of $2000; and (ii) the cost of one-year of monthly subscription fees for use of CORHIO’s PatientCare.24

Oklahoma Challenge Grant:25 The Oklahoma Health Care Authority received

$1,719,086 to implement processes that optimize efficient and well-orchestrated patient transitions, including implementation of a Clinical Documentation Tool (CDT).26 The Oklahoma Health Information Exchange (OHIET) is focusing on improving transitions of care between hospitals and LTC facilities by implementing electronic information exchange to support patient care during and after patient transfers. In addition to the implementation of the technology to support electronic exchange of patient-specific information, they are focusing on improving workflow and processes associated with care transitions to ensure effective use of information to improve patient care.

Selected pilot nursing homes will access the regional HIE via a lightweight-hosted ambulatory EHR installed as a CDT. In addition, a continuity of care document (CCD) would be available for any transfer in or out of a long-term care facility in the Norman Regional Health System pilot region.

23

Office of the National Coordinator for Health Information Technology. Health Information Exchange Challenge

Program: Colorado Regional Health Information Organization (CORHIO). April 2012.

http://statehieresources.org/wp-content/uploads/2012/05/CORHIO-Challenge-Grant-Summary-Report-April-

2012.pdf accessed June 1, 2012. 24

Ibid., accessed June 1, 2012. 25

Office of the National Coordinator for Health Information Technology. Health Information Exchange Challenge

Program: Oklahoma Health Information Exchange (March 2012). http://statehieresources.org/wp-

content/uploads/2012/05/Challenge-Grantee-Summary-Oklahoma_V4-2.pdf accessed June 2, 2012. 26

Melanie Lawrence and Brian Yeaman. Oklahoma's Challenge Grant Care Transitions.

http://www.nga.org/files/live/sites/NGA/files/pdf/1105HIEMELANIE1.PDF accessed May 25, 2012.

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Maryland Challenge Grant:27 The goal of the Maryland Department of Health and Mental Hygiene, who received $1,683,171 in 2011, is to pilot the electronic exchange of clinical documents between pairs of long-term care centers and proximate hospital emergency departments (EDs). The pilot will center on six large long-term care facilities across Maryland, with some services being offered to every facility in the state. Each participating long-term care facility is paired with a hospital in its immediate medical service area. The state will analyze the reduction in average time to transmit such information compared to the status quo, and the effect on hospital readmission rates for patients participating in the pilot versus a control group.28

The technology solutions under development and piloting in the four states could

be re-used by other states and communities to engage LTPAC providers in HIE activities. For example, representatives in Colorado and Oklahoma have expressed an interest in potentially leveraging the tools created by Massachusetts.

Technical Assistance to States through the State Health Policy Consortium (SMPC)

SMPC, established through a HHS contract with RTI in March 2010, facilitates

groups of states in resolving policy issues at a concrete level to enable electronically-exchanged health information across state lines. Building on previous work of the Health Information Security and Privacy Collaboration (HISPC) project, this effort seeks to pursue development of template language for interstate agreements or other similar mechanisms that will enable interstate HIE despite differences in individual state consent laws. The Upper Midwest (UM-HIE) Consortium convened representatives from six states, Illinois, Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin, to work together to create concrete regional solutions to barriers affecting HIE for treatment purposes.29

Infrastructure: Behavioral Health Data Exchange Consortium

Created to pilot the interstate exchange of BH treatment records among treating

health care providers using the Nationwide Health Information Direct protocols, this project involves the creation of draft Policies and Procedures (P&P) for exchange of BH records. The pilot is intent on meeting the requirements of federal regulations at 42 CFR Part 2 and participating state mental health laws. To achieve this, the group of states (Alabama, Florida, Kentucky, New Mexico, Nebraska and Michigan) has created

27

Chesapeake Regional Information Systems for Our Patients (CRISP). Briefing: Maryland Statewide Health

Information Exchange Challenge Grant Application (March 2011).

http://mhcc.dhmh.maryland.gov/hit/hiePolicyBoard/Documents/hie_pb/Resources/MdChallengeGrantBriefing03041

1.pdf accessed June 1, 2012. 28

Ibid., accessed May 22, 2012. 29

Office of the National Coordinator for Health Information Technology. State Health Policy Consortium.

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__state_health_policy_consortium/3035

accessed June 2, 2012.

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sample Part 2 compliant consent forms (one for universal disclosure of health information and one for more limited disclosure).

SAMHSA Health IT Grants: Increase Access to Behavioral Health Services30

Community Health Centers: In September 2011, SAMHSA awarded 47

community health centers serving people with mental and substance use disorders $200,000 each to develop health IT and expand the use of EHRs.31

National Council on Community Behavioral Health Care: The council received

$3.8 million to help community health centers and state-designated agencies implement EHRs.

AHRQ Grant: Geisinger to Extend the KeyHIE Connected Community

This grant will provide additional expansion of the KeyHIE (part of the Keystone

Beacon) connected community (see to additional regional hospitals, long-term care facilities, home health organizations, and physician practices). In addition to expanding participation across the community, KeyHIE will use the five-year AHRQ grant of $2.3 million to make new clinical applications and document types available within the HIE.32

Federal Mental Health Block Grants to Fund Projects to Support Adoption of Health IT and Behavioral/Physical Health Care

Health Information Technology (Health IT)/Health Integration Innovation Mini-

Grant through the Ohio Department of Mental Health (ODMH) to Community Mental Health Centers: ODMH will make available a maximum award of up to $50,000 per applicant for selected activities or work completed between March 1, 2012 and June 30, 2012 by community behavioral health centers that are in the process of moving towards becoming a Community Behavioral Health Center (CBHC) Medicaid health home. Activities that may be supported or enhanced include but are not limited to technical assistance, needs assessments, e-prescribing, data management, certified EHR, and information exchange interfaces which will also include intake from other data sources for utilization

30

SAMHSA Awards Health IT Grants. AHA News Now (September 26, 2011).

http://www.ahanews.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_092611_S

AMHSA&domain=AHANEWS accessed June 1, 2012. 31

Substance Abuse and Mental Health Services Administration. AMHSA announces grants awards totaling up to

$13.2 million to build on Health Information Technology investments (SAMHSA News Release, September 23,

2011. http://www.samhsa.gov/newsroom/advisories/1109231204.aspx accessed June 1, 2012. 32

Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities:

Exchanging Interoperable Patient Assessment Information. Appendix J: Overview of Patient Assessment Summary

(December 2011). http://aspe.hhs.gov/daltcp/reports/2011/StratEng-J.htm accessed May 22, 2012.

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review activities, billing interfaces, tele-health innovations and implementation of patient registries.33

Michigan Prepaid Inpatient Health Plans through Michigan Department of

Community Health (MDCH) FY13 Mental Health Block Grants: Support of $130,000 to each Prepaid Inpatient Health Plan (PIHP), for the purpose of funding systems-level Integrated Healthcare (IH) services enhancement, in one or more domains, of which continuation of promotion of adoption of EHRs is one.34

Patient Protection and Affordable Care Act

The Affordable Care Act includes several provisions that support/advance the use

of health IT/EHRs including on behalf of providers ineligible for the EHR Incentive Programs. In addition to the Medicaid Health Home optional benefit described above that would extend the use of health IT to support care coordination on behalf of persons with mental illness, and persons with chronic conditions including persons who receive long-term care services, the Affordable Care Act also includes provisions that would:

Sec. 6114. National Demonstration Projects on Culture Change and Use of Information Technology in Nursing Homes. The Secretary is authorized to make grants under the demonstration to facility-based settings for the development of best practices in skilled nursing facilities and nursing facilities for the use of information technology to improve resident care. Funds were authorized but not appropriated.

Programs to Promote Elder Justice SEC. 2041. Enhancement of Long-Term

Care. Secretary is authorized to make grants to long-term care facilities for the purpose of assisting such entities in offsetting the costs related to purchasing, leasing, developing, and implementing certified EHR technology. Funds were authorized but not appropriated. Additionally, Section 2041(c) of the Act requires the Secretary to adopt standards for the electronic exchange of clinical data by long-term care facilities. While funds were authorized but not appropriated, ONC is supporting work to advance health IT standards for LTPAC and is seeking feedback on the need for EHR certification criteria for LTPAC providers.

33

Ohio Department of Mental Health. Request for Application: Health Information Technology (HIT)/Health

Integration Innovation Mini-Grant (Federal Fiscal Year 2012). http://mentalhealth.ohio.gov/assets/numbered-

advisories/fy2012/integration-block-grant-rfa-final-2.1.12_4_1.pdf accessed May 31, 2012. 34

Michigan Department of Community Health FY13 Adult Mental Health Block Grant. Request for Applications.

https://www.michigan.gov/documents/mdch/Block_Grant_RFA_31511_348001_7.doc accessed June 1, 2012.

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C. Proposals to Extend Health IT Grants, Demonstrations and Cooperative Agreement Programs EHR Incentives to Ineligible Provider35 The following table identifies some of the actions that some stakeholders have

advanced to extend grants, demonstrations and cooperative agreement programs that have a focus on health IT for some ineligible health providers, such as long-term and post-acute, and behavioral health providers. This summary is not intended to be a complete list of proposals to extend these grant, demonstration, and cooperative agreement programs. Rather the list serves to highlights some of the suggestions by some stakeholders of extending these programs. Further, this list is not intended as endorsement of any one of these options. Instead, the summary serves only to list some of the actions that have been proposed that could support the use of EHR technology by ineligible providers. The text in the table below quotes from the referenced documents.

Stakeholder Group Source and Statement of Proposed Action

Leading Age (formerly known as AAHSA (American Association for Homes and Services for the Aging)) Leading Age 5,800 member organizations, many of which have served their communities for generations, offer the continuum of aging services: adult day services, home health, community services, senior housing, assisted living residences, continuing care retirement communities and nursing homes.

AAHSA Public Policy Priorities 2011 (p.8): The Affordable Care Act provides for a number of exciting opportunities to better integrate acute and post-acute care services through collaboration among a variety of health care providers. This kind of collaboration will require extensive data sharing to ensure continuity and quality of services. Data collection and sharing, in turn, will absolutely depend on the use of health IT. A report by the LeadingAge Center for Aging Services Technology (CAST) discusses the ways in which technology can change the culture, delivery options and financing of health care and long-term services and supports. We support incorporating aging services technologies into accountable care organizations, medical homes and other innovative service delivery systems to help realize cost savings and quality improvements. LeadingAge supports: A pilot program to provide incentives for home health agencies across the country to use home monitoring and communications technologies, giving seniors greater access to the care they need.

35

It should be noted the description of these proposals should not be construed as an endorsement of the proposals.

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Stakeholder Group Source and Statement of Proposed Action

National Association of Home Care (NAHC) Home Care Technology Association of America (HCTAA) HCTAA is a wholly-owned affiliate of the NAHC, and is organized to advance the accessibility and use of technology in home care and hospice settings. HCTAA was established to unite the home care technology industry into a stronger, more effective voice to Congress, the Administration, state legislatures, the home care industry, consumers, and the media. HCTAA believes that home care and hospice providers that are properly equipped with technological solutions will serve a central role in the delivery of health care by ensuring quality, efficiency, and patient care coordination.

NAHC and HCTAA: comments on the definition of “Meaningful Use” of Electronic Health Records (EHR), as required by the American Recovery and Reinvestment Act of 2009” (June 25, 2009) (pp.2-3): We specifically would urge the ONCHIT to ensure that: - HIE grant funding be made to RHIOs/HIEs emphasize the need to include and support

home health care providers to effectively facilitate the electronic exchange of health information across different care settings;

- Grants and loans be made available to home health care providers to plan for and implement certified, interoperable health IT solutions.

…as we have stated, the goal of care coordination requires the exchange of timely health information among all care providers. This goal cannot be achieved unless it is inclusive of home health care and hospice providers. With appropriate resources for implementation and standardization of EHRs, further steps can be taken by the home care and hospice community to meet the objectives of the meaningful use of EHRs and care coordination. NAHC/HCTAA is also exploring strategies to obtain incentives such as small business loans, tax incentives and grants that could be available to LTPAC providers for the adoption of EHRs. NAHC and HCTAA comments on the proposed rule to define the “meaningful use” of Certified Electronic Health Records (EHR) technologies and to establish evaluation criteria that facilitate the flow of incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs (March 15, 2010) (pp.1-2): - Encourage stakeholders to conduct demonstration projects that test the exchange of

meaningful clinical information between EPs, eligible hospitals and home health care and hospice providers and provide data on the outcomes and cost effectiveness of care coordination and the sharing of clinical data amongst a broad scope of health care providers.

- Encourage EPs (physicians) and hospitals in future rulemaking to partner with other health care providers, as defined by Section 3000(3) of the HITECH Act, by directly linking the formation of collaborative partnerships with home health care and hospice providers with the demonstration of meaningful use or by some other incentivizing means.

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Stakeholder Group Source and Statement of Proposed Action

LTPAC Health IT Collaborative Collaborative of associations representing health IT issues for LTPAC providers, professionals, and support services in skilled nursing facilities, nursing facilities, assisted living, home health agencies, etc. Members include: American Health Care Association, American Health Information Management Association, Home Care Technology Association of America, American Society of Consultant Pharmacists, Center for Aging Services Technology, Leading Age, National Association of Home Care and Hospice, National Association for the Support of Long-Term Care, National Center for Assisted Living, Program for All Inclusive Care for the Elderly

April 16, 2009. Inclusion of Long-Term Care Settings in ARRA Funded Projects. Letter to the David Blumenthal (the National HIT Coordinator) (pp.1-2): We are also aware of the ARRA-required investments in grants and loans programs that will be administered through your office to drive the adoption of interoperable health IT nationally. We are contacting you today to provide two recommendations designed to maximize the return on this significant one time investment in the national health IT infrastructure: (1) We recommend that ONC include language in the ARRA requests for HIT grant and

loan proposals advising applicants of the benefits of and need to seek partners from different care settings, including long-term care and providing such help as may be necessary to help identify potential partners (such as providing lists of federally certified providers in various areas).

(2) In addition, we recommend that ONC specify that one of the evaluation criteria for selecting grant/loan recipients will be a preference for those who do partner with long-term care providers (and other health care providers who will not receive financial incentives).

March 15, 2010: Comment letter on the Medicare and Medicaid Programs; Electronic Health Record Incentive Program proposed rules. This rule proposes to define the “meaningful use” of Certified Electronic Health Records (EHR) technologies and to establish evaluation criteria that facilitate the flow of incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and

Medicaid programs.a

LTPAC Recommendations on “Meaningful Use” (pp.1-2):

- Encourage EPs (physicians) and hospitals in future rulemaking to partner with other providers, as defined by Section 3000(3) of the HITECH Act, by directly linking the formation of partnerships with LTPAC providers with the demonstration of meaningful use or by some other incentivizing means…

- Recognize that improved care coordination and the exchange of meaningful clinical information among the professional health care team should involve all health care provider types and that demonstration projects should be devised to demonstrate the exchange of meaningful clinical information between EPs, eligible hospitals and LTPAC providers.

January 18, 2011. President’s Council of Advisors on Science and Technology “Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward” Letter to ONC. (pp.1-2): The report urges the Centers for Medicare and Medicaid Services (CMS) to focus on increasing health information exchange and to exercise its’ influence as a major payer to drive health information exchange. While currently long-term care providers are not eligible for Meaningful Use incentives for adoption of a certified electronic health record under ARRA-HITECH, CMS could leverage federally mandated LTPAC functional status assessments (such as MDS, OASIS and IRF-PAI) to accelerate the adoption of interoperable EHRs in this sector and increase the exchange of health information across health care provider settings. ONC should also support the creation of health data exchange programs that target and engage LTPAC providers. May 6, 2011. LTPAC HIT Collaborative Public Comments on ONC Federal HIT

Strategic Plan 2011-2015.b

OBJECTIVE I.C: Support health information technology adoption and information exchange for public health and populations with unique needs. STRATEGY I.C.3: Support health IT adoption and information exchange in long-term/post-acute, behavioral health, and emergency care settings. The Federal HIT Strategic Plan notes ONC is working with SAMHSA and HRSA to address the policies and standards concerning the unique needs of behavioral health IT adoption and information exchange. The LTPAC Health IT Collaborative supports the inclusion of the unique needs of behavioral health identified in the strategic plan and offers these recommendations below supporting the unique needs of the LTPAC community: - Support for effective care delivery which maintains health care quality outside of the

hospital and acute care setting where most of the elder population--both Medicare and Medicaid beneficiaries as well as “dual eligibles” reside.

a. See http://www.ltpachealthit.org/sites/default/files/MU%20Comments%20March%202010%20v4%205%20%284%29.pdf. b. See

http://www.ltpachealthit.org/sites/default/files/LTPAC%20HIT%20Collaborative%20Comments%20on%20ONC%20Federal%20HIT%20Strategic%20Plan%205_9_11_FINALv2.pdf.

EHR PAYMENT INCENTIVES FOR PROVIDERS INELIGIBLE FOR PAYMENT INCENTIVES

AND OTHER FUNDING STUDY

Files Available for This Report Main Report http://aspe.hhs.gov/daltcp/reports/2013/EHRPI.shtml http://aspe.hhs.gov/daltcp/reports/2013/EHRPI.pdf APPENDIX A. Medicare and Medicaid EHR Incentive Programs

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendA http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendA.pdf

APPENDIX B. Definitions and Certification of EHR Technology

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendB http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendB.pdf

APPENDIX C. Public Health Service Act Section 3000(3) as Added by HITECH Section 13101 -- Provider Analysis

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendC http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendC.pdf

APPENDIX D. Ineligible Provider Characteristics

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendD http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendD.pdf

APPENDIX E. Long-Term and Post-Acute Care Provider Profiles

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendE http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendE.pdf

APPENDIX F. Behavioral Health Provider Profiles

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendF http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendF.pdf

APPENDIX G. Safety Net Provider Profiles

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendG http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendG.pdf

APPENDIX H. Other Health Care Provider Profiles

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendH http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendH.pdf

APPENDIX I. Table Summary of Patient Protection and Affordable Care Act Provisions with Relationship to Ineligible Providers and Health IT Use

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendI http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendI.pdf

APPENDIX J. Behavioral Health Provider Analysis

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendJ http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendJ.pdf

APPENDIX K. Grant, Demonstrations and Cooperative Agreement Programs

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendK http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendK.pdf

APPENDIX L. Loan Programs

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendL http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendL.pdf

APPENDIX M. Technical Assistance Programs

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendM http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendM.pdf

APPENDIX N. Administrative Infrastructure Building Programs

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendN http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendN.pdf

APPENDIX O. Anti-Kickback Statute EHR Safe Harbor Regulations

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendO http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendO.pdf

APPENDIX P. Private Sector Programs to Advance Certified EHR Technology

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendP http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendP.pdf

APPENDIX Q. Regulations for Medical Records

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendQ http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendQ.pdf

APPENDIX R. Technical Advisory Group Summary

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendR http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendR.pdf

APPENDIX S. Evaluating Benefits and Costs of New Incentives for EHR Adoption by

Ineligible Providers http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendS http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendS.pdf

APPENDIX T. CIO Consortium EMR Cost Study Data http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendT http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendT.pdf

APPENDIX U. Abbreviations and Acronyms

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendU http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendU.pdf

APPENDIX V. References

http://aspe.hhs.gov/daltcp/reports/2013/EHRPIap.shtml#appendV http://aspe.hhs.gov/daltcp/reports/2013/EHRPI-appendV.pdf